Case Report

An 80-year-old woman with a medical history of gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD) presented to our department with 5 days of vomiting. She complained of dyspnea and significant weight loss (15 kg) over the last 2 years. On admission, blood pressure, heart rate, respiration rate, and body temperature were within normal limits. Laboratory testing, including chemistries and complete blood count, were normal. Physical examination of abdomen revealed no distention or tenderness, and her bowel sounds were normal with no defecation problems. A nasogastric tube was placed with extreme difficulty, due to persistent vomiting episodes. Chest radiography showed soft-tissue lesions above the diaphragm and large bubbles that overlapped the middle and lower mediastinum, causing the disappearance of the cardiac shadow and the left lower lung field (Figure 1). These findings were attributed to an intrathoracic location of the stomach and part of transverse colon. Gastroscopy demonstrated a massive amount of fluid proximal to a gastric volvulus causing obstruction (Figure 2).

Figure 1. Chest radiography showing soft-tissue lesions above diaphragm (red arrow) and large bubbles that overlapped the middle and lower mediastinum, causing the disappearance of the cardiac shadow and the left lower lung field (yellow arrows).

Gastric volvulus combined with herniation of the colon is an extremely rare finding.1 It is a life-threatening disease that may cause ischemia or perforation because of delayed diagnosis and treatment.2 The classic triad of retching, severe and constant epigastric pain, and difficulty in inserting a nasogastric tube suggests an acute gastric volvulus.3 Usually, it is diagnosed by chest radiograph followed by a barium contrast study or upper gastrointestinal endoscopy. Our patient underwent exploratory laparotomy to repair the stomach, and surgery revealed a large hernia sac with incarceration of the entire stomach and part of transverse colon.

Figure 2. Endoscopic image showing extreme twisting of the stomach (arrow). The torsion of the stomach twisted the fundus and changed the anatomical structure.

Disclosures

Author contributions: M. Galanopoulos wrote the article and is the article guarantor. N. Tsoukalas revised the article.